I argue here for a view I call epistemic separabilism (ES), which states that there are two different ways we can be evaluated epistemically when we assert a proposition or treat a proposition as a reason for acting: one in terms of whether we have adhered to or violated the relevant epistemic norm, and another in terms of how epistemically well-positioned we are towards the fact that we have either adhered to or violated said norm. ES has been appealed to (...) most prominently in order to explain why epistemic evaluations that conflict with the knowledge norm of assertion and practical reasoning nevertheless seem correct. Opponents of such a view are committed to what I call epistemic monism (EM), which states that there is only one way we can be properly evaluated as epistemically appropriate asserters and practical reasoners, namely in terms of whether we have adhered to or violated the relevant norm. Accepting ES over EM has two significant consequences: first, a “metaepistemologial” consequence that the structure of normative epistemic evaluations parallels that found in other normative areas (namely, moral evaluations), and second, that the knowledge norms of assertion and practical reasoning are no worse off than any alternatives in terms of either explanatory power or simplicity. (shrink)

The papers in this issue of the Journal of Medical Ethics address various aspects of five familiar areas of bioethical enquiry: transplantation, genetics, euthanasia, research ethics and professional practice. That these areas, despite all that has been written about them, continue to provoke productive scholarly attention, testifies not only to their existential relevance but also to their moral complexity. Countless human lives will be affected, for better or worse, by how moral decisions in these areas are taken, communicated and implemented. (...) It is of the greatest importance therefore that the ethical thinking informing not only such decisions but also the practices of which they are part, should be both principled and appropriately contextualised. To that end, familiar moral attitudes, assumptions and arguments require repeatedly to be challenged from a variety of perspectives, not ultimately to discover any definitive unravelling of moral complexity, but rather to inform more thoughtful and nuanced responses to the diverse manifestations of that complexity. As Calbresi and Bobbitt have observed: ‘a moral society must depend on moral conflict as the basis for determining morality’. 1 The papers in this issue, written from a variety of cultural, as well as ethical, legal and clinical perspectives, each can assist in that process.For over half a century the subject of organ transplantation has attracted ethical debate. One such ongoing debate, provoked by the severe scarcity of organs for transplantation and a concern to increase their supply, has been about why willing live donors should continue to be prohibited from offering their own organs for sale. Against allowing this, it has often been argued that prohibition protects people in poverty from being driven to, and then harmed by, this desperate last resort. …. (shrink)

Sir Patrick Nairne, who has died aged 91 years, was a distinguished senior civil servant and academic, who among many other accomplishments and achievements, made a significant contribution to the development of medical ethics in the UK. Sir Patrick is perhaps best known in this context as the founding chairman, from 1991 to 1996, of the Nuffield Council on Bioethics, the independent ethics advisory body cofunded by the Nuffield Foundation, the Wellcome Trust and the Medical Research Council, which is deservedly (...) regarded as the closest British equivalent to a national ethics committee. Two or three years prior to the creation of the Nuffield Council however, Sir Patrick had chaired an Institute of Medical Ethics working party on the ethical implications of HIV infection and AIDS, one of a series of enquiries .. (shrink)

When the first issue of this journal was published in April 1975 its inaugural editorial stated: "The aim of the Journal of Medical Ethics is to provide a forum for the reasoned discussion of moral issues arising from the provision of medical care. It will hold no brief for one particular professional, political, or religious viewpoint. The articles it publishes will identify current problems, present factual information, and clarify different moral assumptions. To fulfil these aims the Editors can call on (...) the resources of the disciplines of law, philosophy, and theology, as well as on the whole range of medical and paramedical specialties.1"This prospectus well expressed the ethos of the journal's original publisher, the Society for the Study of Medical Ethics , and was clearly reflected in the content and style of the journal's early issues. It was also reflected in the journal's authorship, which included many leading medical and other academics and professionals of the time, who demonstrated lively engagement with a variety of emerging moral issues. In due course such issues would be well recognised as the substance of ‘medical ethics’, but in 1975, as the editorial also noted, that ‘phrase’ could still ‘create misunderstandings and provoke suspicions (especially perhaps among medical …. (shrink)

The history of the Institute of Medical Ethics has been well recorded. Accounts of its origins in the London Medical Group were published in an academic paper of 2003,1 in the transcript of a Wellcome Witnesses to Twentieth Century Medicine Seminar in 20072 and in a chapter of the 2009 Cambridge World History of Medical Ethics.3 In 2013, 50 years since the inauguration of its first series of lectures and symposia, the LMG as an organisation no longer exists, but its (...) aspirations and achievements are alive and well, both in the Journal of Medical Ethics and in the IME, now exploring a new phase as a membership organisation. Other papers in this issue will discuss the history and prospects of the Journal and Institute. But the LMG, similar medical groups in all other British medical schools and the Society for the Study of Medical Ethics from which the IME derived also have a significant continuing life in the thinking and practice of many medical and healthcare professionals who participated in their activities, and then in turn on those influenced by their thinking and practice. The LMG, it could be said, is ‘no more’ an organisation ‘Now but a whole climate of opinion’.4A bottom-up evolutionThe first medical students to be involved in the LMG may not have foreseen its influence on their future careers, but many were aware of being part of something new and exciting. One of those with whom the first lecture series was planned was Margaret Lloyd . "The beginning of the LMG in 1963 was an exciting time for medical students in London. As a mature student entering St Mary's Hospital Medical School … ". (shrink)

Isaac Levi (1980) targets an implicit tension in C.S. Peirce’s epistemology, one that exists between the need to always be open-minded and aware of our propensity to make mistakes so that we do not “block the road of inquiry,” and the need to treat certain beliefs as infallible and to doubt only in a genuine way so that inquiry can proceed in the first place. Attempts at alleviating this tension have typically involved interpreting Peirce as ascribing different normative standards to (...) different areas of inquiry. I argue here that such “double-standard” interpretations face significant problems. I offer instead an interpretation of Peirce on which the differences between different areas of inquiry are descriptive rather than normative. Such a view resolves Levi’s tension while interpreting Peirce as consistently subscribing to one normative standard for all inquiry. (shrink)

This penetrating book sheds light on the psychology of fundamentalism, with a particular focus on those who become extremists and fanatics. What accounts for the violence that emerges among some fundamentalist groups? The contributors to this book identify several factors: a radical dualism, in which all aspects of life are bluntly categorized as either good or evil; a destructive inclination to interpret authoritative texts, laws, and teachings in the most literal of terms; an extreme and totalized conversion experience; paranoid thinking; (...) and an apocalyptic world view. After examining each of these concepts in detail, and showing the ways in which they lead to violence among widely disparate groups, these engrossing essays explore such areas as fundamentalism in the American experience and among jihadists, and they illuminate aspects of the same psychology that contributed to such historical crises as the French Revolution, the Nazi movement, and post-Partition Hindu religious practice. (shrink)

Knowledge of the ethical and legal basis of medicine is as essential to clinical practice as an understanding of basic medical sciences. In the UK, the General Medical Council (GMC) requires that medical graduates behave according to ethical and legal principles and must know about and comply with the GMC’s ethical guidance and standards. We suggest that these standards can only be achieved when the teaching and learning of medical ethics, law and professionalism are fundamental to, and thoroughly integrated both (...) vertically and horizontally throughout, the curricula of all medical schools as a shared obligation of all teachers. The GMC also requires that each medical school provides adequate teaching time and resources to achieve the above. We reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise. In this paper we set out an updated indicative core content of learning for medical ethics and law in UK medical schools and describe its origins and the consultative process by which it was achieved. (shrink)

Background: The Declaration of Helsinki, the World Medical Association’s statement of ethical guidelines regarding medical research, is published in the three official languages of the WMA: English, French and Spanish.Methods: A detailed comparison of the three official language versions was carried out to determine ways in which they differed and ways in which the wording of the three versions might illuminate the interpretation of the document.Results: There were many minor linguistic differences between the three versions. However, in paragraphs 1, 6, (...) 29, 30 and in the note of clarification to paragraph 29, there were differences that could be considered potentially significant in their ethical relevance.Interpretation: Given the global status of the Declaration of Helsinki and the fact that it is translated from its official versions into many other languages for application to the ethical conduct of research, the differences identified are of concern. It would be best if such differences could be eliminated but, at the very least, a commentary to explain any differences that are unavoidable on the basis of language or culture should accompany the Declaration of Helsinki. This evidence further strengthens the case for international surveillance of medical research ethics as has been proposed by the WMA. (shrink)

Objective: To determine whether the marks in the third year Objective Structured Clinical Examination were affected by the collusion reported by the students themselves on an electronic discussion board.Design: A review of the student discussion, examiners’ feedback and a comparison of the marks obtained on the 2 days of the OSCE.Participants: 255 third year medical students.Setting: An OSCE consisting of 15 stations, administered on three sites over 2 days at a UK medical school.Results: 40 students contributed to the discussion on (...) the electronic discussion board. The main points raised were perceived inequity between students who did, or did not, have prior knowledge of the station content, and the lack of honesty and professionalism of their peers. Most contributors claimed to have received, or knew of others receiving, prior knowledge, but none confessed to passing on information. No significant difference was observed in the overall mark for the OSCE on day 1 ) and day 2 ). On day 2, marks were considerably greater for four stations and markedly lower for three stations. It was not obvious why collusion should affect these station marks. A clear indication of the effects of collusion could only be obtained from a single subsection of an individual station where 82 students on day 2 incorrectly gave the diagnosis from day 1.Conclusion: Marks do not provide a sound inference of student collusion in an OSCE and may mask the aspects of professional development of students. (shrink)

Ethics in nursing: continuity and change -- Cultural issues, methods and approaches to nursing ethics -- Nursing ethics: what do we mean by 'ethics'? -- Becoming a nurse and member of the profession -- Power and responsibility in nursing practice and management -- Professional responsibility and accountability in nursing -- Classical areas of controversy in nursing and biomedical ethics -- Direct responsibility in nurse/patient relationships -- Conflicting demands in nursing groups of patients -- Ethics in healthcare management: research, evaluation and (...) performance management -- The political ethics of healthcare: health policies and resource allocation -- Corporate ethics in healthcare: strategic planning and ethical policy development -- Making moral decisions and being able to justify our actions -- The relevance of moral theory: justifying our ethical policies. (shrink)

Medical ethics, principles, persons, and perspectives is discussed under three headings: History, Theory, and Practice. Under Theory, the author will say something about some different approaches to the study and discussion of ethical issues in medicine—especially those based on principles, persons, or perspectives. Under Practice, the author will discuss how one perspectives based approach, hermeneutics, might help in relation first to everyday ethical issues and then to public controversies. In that context some possible advantages of moving from controversy to conversation (...) will be explored; and that will then be illustrated with reference to a current controversy about the use of human embryos in stem cell therapy research. The paper begins with history, and it begins in the author’s home city of Edinburgh. (shrink)

Was society’s response adequate in the cases of Mrs Pretty and Ms B?On the 11th of May, less than two weeks after losing her final legal appeal, Mrs Diane Pretty died, under sedation and in the care of a hospice. It was not the end she had pursued through the English High Court, the Court of Appeal, the House of Lords, and the European Court of Human Rights. Paralysed by motor neurone disease and unable to take her own life, Mrs (...) Pretty wanted her husband to be allowed to help her to die when they decided the time had come. But in England, assisting suicide is a crime, although suicide itself no longer is, and the English courts refused Mrs Pretty’s request to grant her husband legal immunity. In turning to the European Court of Human Rights, Mrs Pretty argued that the English courts’ refusal had violated the European Convention on Human Rights.The European court, however, judged that there had been no violation. The right to life could not be construed as conferring a “right to die”, and consequently the state could not be required to “sanction actions intended to terminate life” in order to protect Mrs Pretty from the “inhuman or degrading treatment” to which she claimed the law on assisted suicide subjected her. The right to respect for private life , moreover, had to be exercised “in accordance with the law” of the state concerned. “States were entitled to regulate through the operation of the general criminal law activities which were detrimental to the life and safety of other individuals”; and such activities were what the English law against assisting suicide was designed to prevent. Exceptions to this law could not be allowed without undermining the …. (shrink)

The symposium in this issue, on equality and disability, helps to clarify some areas of continuing disagreement in disability studies, but also uncovers substantial consensus. All of the contributors appear to endorse John Harris's statement that “No disability, however slight, nor however severe, implies lesser moral, political or ethical status, worth, or value”.1 It seems safe to assume, moreover, that few if any readers of the Journal of Medical Ethics are likely to disagree with this, or indeed to challenge Kate (...) Diesfeld's initial assumption that “Generally speaking, it is both immoral and unlawful to discriminate between people on the ground of disability”.2Some, of course, might challenge Diesfeld's choice of the word “between” rather than “against”. What is generally agreed to be both immoral and unlawful is discrimination in the modern sense of treating people unjustly on the basis of distinctions that are not morally relevant to the matter in hand. It is neither immoral nor illegal, for example, for a transport employee to discriminate between members of the travelling public in order to offer some but not others the use of a wheelchair or a wheelchair ramp. Nor is it immoral or illegal for society to discriminate between its members through legislation which offers, to some but not others, special forms of aid or protection, based on the recognition of their respective disabilities.Legislation designed to protect people …. (shrink)

AIDSThe sudden appearance of a truly new disease is a wake-up call. A new global pandemic of an infectious agent, transmitted through sexual contact and blood, affecting alienated and/or deprived people and communities, infectious throughout, that causes a slowly progressive breakdown of defence against other infectious diseases, as well as causing dementia in some, and leads to a premature death, occurring in an era of extensive travel and rapid communication, is a veritable tocsin. These crude ingredients of AIDS as a (...) medical and social phenomenon, blended with the poignant personal histories revealed to clinical professionals, spiced — as if this were necessary — by the fear, the prejudice, the wild theorising and the voyeurism, have presented a substantial challenge to practical medical ethics.Familiar ethical debates have been reopened with new perspective and insight, others have been examined thoroughly for the first time. Building on the major developments in medical ethics over recent decades, AIDS has provided an opportunity, indeed a necessity, for its maturation. It continues to present new issues for debate, while those that were present from the outset continue to perplex us, as this issue of the journal should show. In teaching, AIDS offers a plethora of examples to illustrate most of the central tenets and tensions of medical ethics. As an exemplar, it has provided preparation and precedent for addressing some of the issues emerging from new challenges, such as screening for susceptibility to genetic disease.AJPBereavementThe word comes from the same germanic root as “to be robbed excessively”. Bereavement is an intensely personal and disorienting experience, to which people can react with denial, anger, guilt or depression, sometimes prolonged. In Western countries nowadays it is most commonly experienced in mid-life through the death of a parent, or in old age through that of a …. (shrink)

Concepts such as disease and health can be difficult to define precisely. Part of the reason for this is that they embody value judgments and are rooted in metaphor. The precise meaning of terms like health, healing and wholeness is likely to remain elusive, because the disconcerting openness of the outlook gained from experience alone resists the reduction of first-person judgments (including those of religion) to third-person explanations (including those of science).

It began in 1992, with two men walking out of a television studio. Colin Blakemore, Oxford Professor of Physiology, is a quiet-spoken, eloquent defender of the use of animals in medical research. Les Ward, Director of the Edinburgh-based Advocates for Animals, is a passionate opponent of animal use. Bringing them together in front of an invited audience with strong opinions on both sides would make the sparks fly and be good viewing. But Blakemore and Ward, retiring after yet another bout (...) that neither side won, were dissatisfied. Both knew that media debates gave them a chance to highlight the flaws and evasions in the other side's arguments, and perhaps to recruit some new supporters to their own. But Ward realized that this was not enough to achieve the radical change he wanted: replacement of animals by other methods. And Blakemore disliked defending animal experiments against all comers. He too wanted to replace animals, albeit only when this could be done without forgoing the real benefits of research. (shrink)

Like many other locals, I was unprepared for the global media's invasion of Roslin. The former mining village just outside the southern city limits is best known to most Edinburgh citizens for its tiny, ornately carved medieval chapel. Constructed for Crusading Knights and long associated with Freemasons, Rosslyn Chapel was made famous by Sir Walter Scott's LayoftheLastMinstrel. Nowadays it is visited, in coachloads, by devotees of less literary and historically more dubious esoterica, many of whom believe that the Holy Grail (...) and/or a version of the gospels are buried beneath it. In the local media, demands for the chapel's foundations to be excavated in search of secret clues to the meaning of life, death, and everything, have figured just as prominently as articles agonizing over scientific developments at the Roslin Institute, half a country mile away. (shrink)

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or (...) breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients. (shrink)

This book is the result of a three-year study undertaken by a multidisciplinary working party of the Institute of Medical Ethic (UK). The group was chaired by a moral theologian, and its members included biological and ethological scientists, toxicologists, physicians, veterinary surgeons, an expert in alternatives to animal use, officers of animal welfare organizations, a Home Office Inspector, philosophers, and a lawyer. Coming from these different backgrounds, and holding a diversity of moral views, the members produced the agreed report as (...) a result of detailed and rigorous discussions. The book sets out facts about animal experiments and about animal abilities to experience pain, distress and anxiety. There is a detailed examination of the moral claims related to the benefits likely to accrue from animal research, and of strategies for weighing these benefits against the harm caused to animals, in order to decide whether particular research projects ought or ought not to proceed. This leads to consideration of the statutory and non-statutory controls which safeguard standards in such research. The final section explores a variety of philosophical arguments about the use of animals in research, and offers a philosophical justification for the Working Party's more practical conclusions. Written in clear, nontechnical language, this book is accessible to lay people as well as to scientists. It is the first such document to emerge from a meeting of people with such widely differing views on this highly controversial subject, and represents a major contribution towards informing and raising the quality of contemporary debate. The book is unique in drawing together material and ideas never before found in one volume. It will interest a broad spectrum of readers, from ethicists and animal rights advocates to scientific researchers and laboratory administrators, along with general readers concerned about this compelling issue. (shrink)

This symposium discussed bioethics teaching, research and documentation and also research ethics committees. An international convention for the protection of the integrity of the human body was called for, as was a new European Committee on Ethics. 'The genetic impact' was a major preoccupation of the symposium.

An Institute of Medical Ethics working party supports the view that explicit permission should normally be sought in the case of testing for HIV antibody. It discusses this in relation to anonymised HIV testing for epidemiological purposes, concluding that this is to be welcomed, given certain safeguards. It next argues that pregnant women may have a greater and more immediate need than others to know their HIV status. It concludes that this need does not justify testing them without their permission, (...) but can be met by voluntary diagnostic testing on an 'opting-out' basis, supported by adequate briefing. (shrink)

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

The author of this comment suggests that some of the important points made by Dr Adrian Rogers are vitiated by a tendency to contrast the worst of modern medical practice with an over-idealised view of the past. The state of medical ethics today, the author suggests, is more hopeful than Dr Rogers allows.

This commentary focuses on two moral values implied by the case study but not specified in the working party's conclusions, namely equitable treatment of the most vulnerable and the value of political government.

For much of human history the idea of a right to life has not seemed self-evident. The credibility of the idea appears to depend on a particular kind of intuition concerning the nature of the world. In this paper, the kind of intuition involved is related to the idea of a covenant, illustrated by that of marriage. The paper concludes by suggesting that talk about responsibilities may be more fruitful than talk about rights.